Diabetes Update Glycemic Control Raymond O. Estacio, MD Denver Health Associate Professor of...
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Diabetes Update Diabetes Update Glycemic Control Glycemic Control Raymond O. Estacio, MD Raymond O. Estacio, MD Denver Health Denver Health Associate Professor of Medicine Associate Professor of Medicine University of Colorado, Denver School of University of Colorado, Denver School of Medicine Medicine Director of Medical Affairs, Colorado Director of Medical Affairs, Colorado Prevention Center Prevention Center
Diabetes Update Glycemic Control Raymond O. Estacio, MD Denver Health Associate Professor of Medicine University of Colorado, Denver School of Medicine
Diabetes Update Glycemic Control Raymond O. Estacio, MD Denver
Health Associate Professor of Medicine University of Colorado,
Denver School of Medicine Director of Medical Affairs, Colorado
Prevention Center
Slide 2
Why are We Concerned about Diabetes? Every 24 hours... 3,600
new cases of diabetes are diagnosed 3,600 new cases of diabetes are
diagnosed 580 people die of diabetes-related complications 580
people die of diabetes-related complications 225 people have a
diabetes-related amputation 225 people have a diabetes-related
amputation 120 people with diabetes progress to end-stage renal
disease 120 people with diabetes progress to end-stage renal
disease 55 people with diabetes become blind 55 people with
diabetes become blind www.diabetes.orb
Slide 3
Increasing Prevalence of Diagnosed Diabetes in US Adults
19942005
Slide 4
The Burden of Diabetes in the United States 21 million
Americans have diabetes 21 million Americans have diabetes 6 th
leading cause of death in the US (225,000) 6 th leading cause of
death in the US (225,000) Direct and indirect cost = $174 billion
Direct and indirect cost = $174 billion Diabetes accounts for 19%
of health care expenditures in the US Diabetes accounts for 19% of
health care expenditures in the US Source: American Diabetes
Association
Slide 5
ADA, Diabetes Care. 2003;26:917-932 Projected Increase in the
US Population with Diagnosed Diabetes by 2020 by Ethnicity
Reduction in Life Expectancy According to Age at Time of
Diagnosis Years Roper et al, BMJ 2001
Slide 8
Ischemic heart disease % of Deaths Geiss LS et al. In: Diabetes
in America. 2 nd ed. 1995; chap 11. Mortality in People with
Diabetes Causes of Death Other heart disease Diabetes CancerStroke
Infection Other
Slide 9
Trends in Mortality Rates for CVD in NHANES Subjects with and
without Diabetes Gregg et al., Ann Inttern Med 2007 Progress in
reducing mortality rates among persons with diabetes has been
limited to men. Diabetes continues to greatly increase the risk for
mortality, particularly among women. Mortality rates are calculated
as annual deaths per 1000 persons
Slide 10
Glycemic Control in Type 2 Diabetes
Slide 11
Glycemic Control on Diabetic Microvascular Complications Type 2
UKPDS 8 7% 17-21% 24-33% - HbA1c Retinopathy Nephropathy Neuropathy
Type 1 DCCT 9 7% 76% 54% 60% Type 2 Kumamoto 9 7% 69% 70% - DCCT
Research Group, NEJM 1993, Ohkubo et al., Diab Res Clin Pract 1995,
UKPDS Group, Lancet 1998
Slide 12
Glycemic Control and Diabetic Macrovascular Complications
Epidemiologic data demonstrating a 2 4x increased in CVD outcomes
Epidemiologic data demonstrating a 2 4x increased in CVD outcomes
Blood Sugar Related to Lipoproteins, Syndrome X, Clotting, AGE,
Renal Disease Therefore, improved glycemic control over a long
period of time should lead to a decrease in CVD outcomes?
Slide 13
Veterans Affairs Diabetes Feasibility Study 150 patients over 2
years Randomized to Standard versus Intensive therapy 2.07%
separation of glycosylated hemoglobin (HbA1c) 61 new cardiovascular
events 32% intensive treatment 20% standard treatment (P =.10).
Intensive Standard Abraira et al., Arch Int Med 1997
Slide 14
UKPDS 3800 newly diagnosed type 2 DM patients Randomized to
Intensive versus Standard therapy Over 10 years of follow up A1C 7%
vs 8%
Slide 15
UKPDS Aggregate endpoints by treatments
EndpointIntensiveConventionalRR for Intensive Treatment (N=2729)
(N=1138) Any diabetes endpoint 963 438 0.88 (0.79-0.99)
Diabetes-related death 285 129 0.90 (0.73-1.11) All-cause mortality
489 213 0.94 (0.8-1.10) MI 387 186 0.84 (0.71-1.00) Stroke 148 55
1.11 (0.81-1.51) Amputation/ PVD death 29 18 0.65 (0.36-1.18)
Microvascular 225 121 0.75 (0.60-0.93) UKPDS Group, Lancet
1998
Slide 16
DCCT/EDIC Metabolic Results DCCT Intervention DCCT Intervention
S t u d y Y e a r DCCT 1 2 3 4 5 6 7 8 9 EDIC Observation EDIC
ObservationTraining EDIC Conventional EDIC mean 8.2% Intensive EDIC
mean 8.0% DCCT/EDIC Study Research Group, NEJM 2005
Slide 17
Conventional Intensive Non-Fatal MI, Stroke or CVD Death
Cardiovascular Events 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18 19 20 21 Number at Risk Intensive: 705 686 640 118 Conventional:
721 694 637 96 Years from Study Entry 0.00 0.02 0.04 0.06 0.08 0.10
0.12 Cumulative Incidence Risk reduction 57% 95% CI: 12, 79
Log-rank P = 0.018 DCCT/EDIC Study Research Group, NEJM 2005
Slide 18
Recent Studies Evaluating Glycemic Control on CVD ACCORD ACCORD
ADVANCE ADVANCE VADT VADT
Slide 19
ACCORD: Study design ACCORD Study Group. Am J Cardiol.
2007;99(suppl):21i-33i. www.accordtrial.org *Statin + fibrate vs
statin, treatment group assignment blinded until end of trial
Primary outcome: CV death, MI, stroke Glycemia trial N = 10,251
with T2DM and existing CVD or additional CV risk factors 1178 1184
1193 1178 1383 1370 1374 1391 5128 5123 2362237127532765 SBP